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OFFICE SCHEDULING POLICIESTo Our Patients:The following information about our of?ce policies is provided for your understanding. We feel that the more you know about our policies and methods of practice, the more we can be of service to you and avoid possible misunderstandings and frustration.When making an appointment please realize we design our schedule to offer individualized quality care for you. We need 48 hours (two working days) notice to change an appointment. This advance notice allows us to offer this valuable chair time to another patient who is in need of treatment. We realize that circumstances sometimes prevent our patients from keeping their appointment. Regretfully you will be billed a minimum of $75.00 for the time lost.I have read the above information.___________________________________ ________________ Signature DateIGN HERETHE FACTS ABOUT FILLINGS (Dental Board of California Publication)I acknowledge I have received a copy of the Dental Materials Fact Sheet dated May 2004, from Beautiful Smiles Dental as required by state law.___________________________________ _________________ Signature Date INFORMATION FOR OUR PATIENTS WITH DENTAL INSURANCESince we feel strongly that our patients deserve the best dental care we can provide, and in an effort to maintain a high quality of care, we would like to share some facts about dental insurance with you.As a courtesy to our patients, we will submit all insurance claims on your behalf and will handle any correspondence that your insurance company may have. We ask that you pay the estimated patient portion at the time of service. If there is any residual after insurance pays, we will send that on to you for ?nal payment. We submit pre-determinations on a limited basis. Pre-determinations are not a guarantee of payment, only an estimate. Pre-determinations take approximately 4-6 weeks to get a response back. The estimates we are given via fax, telephone or insurance website are just as accurate but again are only an estimate.We consider our relationship with YOU to be our primary importance and will always make our recommendations to you based on what we believe is the very best treatment for you regardless of your insurance coverage. We hope you understand that your insurance coverage is a contract between you and your insurance company, or between your employer and the insurance company. Therefore, as the patient, it is ultimately your responsibility to deal with your insurance company and/or your employer. We will assist in any way possible to maximize your dental insurance bene?ts, but to reemphasize; we have no relationship or responsibility to your insurance company.FACT #1: Dental Insurance is not meant to be a “PAY-ALL”; it is only meant to be an aid.FACT #2: Many plans tell their insured that they will be covered “up to 80%” or “up to 100%”. In spite of what you’re told, we’ve found many plans cover 40% to 50% of an average fee. Some plans pay more…some pays less. The amount your plan pays is determined by the contribution you and your employer make to your dental plan. The smaller the contribution paid into the plan for “insurance”, the less you’ll receive. It is your responsibility to advise us of your insurance coverage and restrictions.FACT #3: It has been the experience of many dentists that some insurance companies tell their customers that “fees are above the usual and customary fees” rather than saying to them that “our bene?ts are low”. Remember you get back only what you and your employer put into your insurance coverage less the profits of the insurance company. In dealing with over 1000 dental insurance plans, most plans cover a percentage of our fees.FACT #4: Each plan utilized in our of?ce has different percentages, deductibles, maximums, procedures covered, and varying fees that the plan will allow. We will do our very best to make as close a calculation as possible of what your insurance plan will cover. However, as we cannot estimate precisely, there may be variances for which the patient is individually responsible.FACT #5: Insurance carriers DO NOT cover many routine dental services. We make our recommendations based on your needs and not on what your insurance may or may not cover.Please do not hesitate to ask us any questions about our of?ce policies. We want you to be comfortable in dealing with these matters and we urge you to consult us if you have any questions regarding our services and/or fees. If you have any questions regarding your insurance, please contact your insurance carrier regarding the speci?cs and details of the plan they are operating on your behalf.SIGN HERESignature: ____________________________________________ Date: ________________________ACKNOWLEDGEMENT OF RECEIPTFOR NOTICE OF PRIVACY PRACTICES**You May Refuse to Sign This Acknowledgement**I, ____________________________________, have received a copy of this office’s Notice of Privacy Practices._____________________________________Print name_____________________________________Signature_____________________________________DateFor Office Use OnlyWe attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:__ Individual refused to sign__ Communications barrier prohibited obtaining the acknowledgement__ An emergency situation prevented us from obtaining acknowledgement__ Other (Please Specify____________________________________________________________________________________________________________________________________________________________PLEASE HANDLE ME WITH CARE! PLEASE FILL OUTPut a check mark in the box next to the statement(s) that concerns you or describes how you feel. Please share this information with us during your dental exam.I gag easily. I feel out of control when I’m lying down on the dental chair. I have not been to the dentist for a long time, and I feel uncomfortable about what you will say about my teeth and my dental hygiene.Pain relief is a top priority for me. I don’t like shots for I’ve had a bad reaction to shots. Please tell me what I need to know about my mouth in order to make an informed decision. My teeth are very sensitive. I don’t like the sound of that tool that makes the picking and scraping noise.I don’t like cotton in my mouth. I don’t like the noise of the drill.Please respect my time. I don’t want to be left sitting in the reception area or dental chair. I would prefer to have as much done during my appointments to minimize my visits.I want to know the cost up front. No money surprises please. I have difficulty listening and remembering what I hear while sitting in the dental chair. I have health problems that we need to discuss. Thank you for taking the time to share your concerns with us. This will give us a better understanding of your individual needs and will make a big difference in how you are treated and how you feel about coming to the dentist.Dr. Zaihly Azar- Santana, DDSand staffWritten Financial PolicyThank you for choosing Beautiful Smiles Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options:You can choose from:- Cash, Visa?, MasterCard? or American Express?- Convenient Monthly Payment Options? from CareCredit Healthcare Credit CardAllow you to pay over timeNo annual fees or pre-payment penaltiesPlease note:Beautiful Smiles Dental requires payment at the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.For plans requiring multiple appointments, alternative payment arrangements may be provided. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.?A fee of $75 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.Beautiful Smiles Dental charges $30 for returned checks.If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Patient, Parent or Guardian SignatureDatePatient Name (Please Print)?Subject to credit approval?However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. ................
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